Introduction
The intraoperative monitoring phase is the most crucial period of the entire surgical experience of the patient. The expertise and specialized skills of the OR nurse, especially related to monitoring of the patient and the entire surgical team, are vital to the effective and safe conduction of the surgery.
Definition
Intraoperative monitoring, which includes intraoperative neurological monitoring (IONM), refers to the continuous assessment of the physiological functioning of all vital organs of the patient especially related to the central nervous system (brain, spinal cord, and nerves) during the surgery.
Purposes
The intraoperative monitoring serves to;
- Assess the integrity of the neural structures and consciousness during the procedure.
- Protect the patient from life-threatening situations during surgery.
- Detect any critical risk to the patient.
- Enable the surgical team to initiate early and immediate interventions to reverse the risk.
- Minimize long-term permanent postoperative damage.
- Safeguards the surgical team from missing out any crucial interventions.
Indications
This procedure is recommended for
- Individuals at risk of complication/injury during surgical procedures.
Routinely Measured Parameters
The parameters measured in most surgical procedures include the following:
- The heart’s electrical activity via an electrocardiogram.
- The respiratory rate.
- The blood pressure, which can be measured by both invasive and noninvasive means.
- The body temperature via temperature probes or thermometers, especially when general anesthesia lasts over 30 minutes in duration.
- The cardiac output.
- The arterial blood oxygen level measured by a pulse oximeter or a photoelectric sensor clipped over the finger or toe.
- Mixed venous oxygenation.
- Pulmonary functions such as end-tidal carbon dioxide.
- Intracranial pressure monitoring in patients suffering from trauma to the head, or raised intracranial pressure because of brain tumors, edema, or intracranial hemorrhage (the sensor is inserted through a burr hole made in the skull; these are important in detecting rises in the pressure inside the head, and recording the pattern for comparison).
Modalities of Intraoperative Neurophysiological Monitoring (IONM)
Each monitors a specific neural pathway, and they are as follows:
- Evoked potentials: These include somatosensory evoked potential (SSEP), motor evoked potential (MEP), brainstem auditory evoked potential (BAEP), and visual evoked potential (VEP). SSEP monitors the dorsal column-medial lemniscus pathway, which mediates tactile discrimination, vibration, and proprioception.
- Electroencephalography (EEG): The electrical activity measured by EEG is generated by groups of pyramidal neurons.
- Electromyography (EMG): EMG monitors somatic efferent nerve activity and evaluates the functional integrity of individual nerves.
Multimodal intraoperative neuromonitoring (IONM) is recommended as an effective way to avoid permanent neurological injury during surgical procedures.
Intraoperative phase monitoring:
Intraoperative monitoring is a vital nursing responsibility during surgery, ensuring patient safety, physiological stability, and timely intervention.
1. Vital Signs & Hemodynamic Monitoring
- Heart rate, blood pressure, respiratory rate, SpO₂, and temperature
- Continuous ECG monitoring for arrhythmias
- Invasive monitoring (e.g., arterial lines, central venous pressure) if indicated
2. Anesthesia Monitoring Support
- Collaborate with the anesthesiologist to monitor depth of anesthesia
- Observe for signs of hypoventilation, hypotension, or allergic reactions
- Ensure airway patency and assist with intubation if needed
3. Fluid & Electrolyte Balance
- Monitor IV fluid administration, blood loss, and urine output
- Assess for signs of hypovolemia or fluid overload
- Assist in blood transfusion procedures if required
4. Temperature Regulation
- Prevent hypothermia using warming blankets or fluid warmers
- Monitor core temperature, especially in long or open procedures
5. Aseptic Technique & Infection Control
- Maintain sterile field and monitor for breaks in technique
- Ensure proper surgical hand scrub, gowning, and gloving
- Administer prophylactic antibiotics as ordered
6. Neurological & Positioning Safety
- Monitor for signs of nerve compression or pressure injuries
- Ensure proper patient positioning to maintain circulation and prevent injury
7. Documentation & Communication
- Record all intraoperative events, medications, and interventions
- Communicate with the surgical team and advocate for the patient
- Document specimen handling, surgical counts, and equipment use
Roles and Responsibilities of the OT Nurse Related to Monitoring and Care
- Provide the patient with efficient and reliable perioperative nursing treatment.
- Keep surgical facilities up-to-date and compliant with competency requirements.
- Complete all the physician’s orders, prescribe medications, and offer timely treatments and examinations to patients.
- Establish and carry out nursing care plan for the designated patient.
- Monitor and report changes in the patient’s vital signs.
- Monitor blood loss and urine output.
- To ensure the safety of the operating personnel and the patient, perform proper use, treatment, and handling of surgical equipment.
- Maintain up-to-date and in-depth sterile techniques and skills.
- To meet patient care needs, maintain constant communication with the operating team and other medical personnel.
- Assist in the ordering, storage, and maintenance of surgical supplies and equipment.
- Prepare the OR with sterile surgical instruments, linens, and materials that will be required during the operation.
- Keep the OR clean and orderly.
- Prepare patients for surgery by washing and disinfecting body areas.
- Safety is the highest priority in positioning of the patient.
- Place both feet simultaneously to prevent dislocation of the hip.
- Always apply knee strap. Arms should not be more than 90°.
- Prepare and apply the cautery pad. Cautery is used to stop bleeding.
- The following are nursing assessment during and after anesthesia:
- Assess oxygenation objectively for patients on anesthesia, for example, using pulse oximeter.
- Clinical signs such as chest excursion, observation of the reservoir breathing bag, and auscultation of breath sounds are useful to assess the adequacy of ventilation.
- Continuously monitor for the presence of expired carbon dioxide.
- Monitor vital signs.
- Observe the patient and record the time when motion and sensation of the legs and the toes return.
- Monitor for side effects of anesthesia such as the following:
- Some numbness or reduced feeling in part of your body (local anesthesia).
- Nausea and vomiting.
- A mild drop in body temperature.
- Maintain up-to-date and reliable medical records and recovery charts.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884.
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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